Fig. 16.1
Application of RE-AIM model to overcoming barriers to injury prevention in the military setting
In the military setting, other barriers exist that may prevent wide-scale adoption of injury prevention and health promotion interventions that have proven to be effective over time. These barriers exist at the: (1) corporate or strategic level (policy makers, senior officials, etc.), (2) organizational or operational level (medical treatment facilities, operational level units, etc.), and (3) individual or tactical level (health-care providers, service members, family members, tactical level units, etc.). Therefore, this chapter addresses barriers to injury prevention with respect to the RE-AIM model at these three levels.
Overview of the RE-AIM Model
In 1999, the reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) model was described by Glasgow et al. [4, 8] in an effort to identify the breadth of influences that promote the success or failure of health promotion efforts. They argue that the multitude of efficacy studies conducted with subjects, settings, and/or interventions that are biased toward the success of the proposal are destined to fail when applied outside the controlled setting of the research. Glasgow et al. also stress that the intervention proposal should include a plan to address all five of the major dimensions of RE-AIM. The specificity of these dimensions has made the RE-AIM model an exceptional framework around which program analysis and evaluation can be built in health promotion and injury prevention.
The RE-AIM model includes parameters addressing the micro or individual aspects of program success: reach and efficacy/effectiveness, as well as parameters focused on the implementing organization or setting: adoption, implementation, and maintenance. Glasgow and his coauthors [8] define reach as the number/percentage of all appropriate individuals that participate in the intervention as well as a critique of their representativeness of the population as a whole (e.g., age, gender, socioeconomic status, literacy, severity of condition). They emphasize the importance of accurately identifying the true size of the applicable population to appropriately gauge the degree of reach . The efficacy or effectiveness criterion addresses the measureable impact on the chosen outcome measure as demonstrated by high-quality evidence. These two criteria as well as the others are considered multiplicative factors whose interaction can significantly impact expected outcomes. For example, a health promotion program aimed at reducing childhood obesity that demonstrated 80 % effectiveness at reducing body mass index (BMI) in a controlled/funded research effort but only reaches 15 % of 1000 potential beneficiaries in a community effort is only successful in 120 people. Similarly, a less effective (40 %) intervention that reaches 80 % of potential beneficiaries is ultimately successful in 320 people [8].
Adoption is the first organizational level criterion and is defined as the number/percentage of “settings” that elect to implement the chosen program [8]. This criterion also includes commentary on the representativeness of those that participate compared to those settings that elect not to participate. These comparisons should include comments regarding staffing, funding, and facilities in order to accurately identify barriers to broader implementation. Implementation refers to the degree to which the selected program is delivered to the intended audience in accordance with the defined protocol. Implementation can be enumerated as successful participant contacts, percentage of times content is delivered accurately, or number/percentage of staff across settings that elect to participate. Similar to other criteria, it is important to identify characteristics of those staff that are compliant and consistently deliver content or choose to participate. Are those that participated representative of all personnel? How do they compare to published results or standards?
The final criterion of the RE-AIM model is maintenance. Maintenance has applicability at both the individual and organizational (setting) levels. Organizationally, maintenance refers to the long-term incorporation of the intervention into the daily practice, culture, and corporate policies greater than 6 months beyond the original implementation period [4]. Individually, maintenance can be reported as long-term (> 6 months) incorporation of promoted behaviors by percentage attrition .
The breadth and depth of analysis encouraged by the RE-AIM model provides a strong foundation for addressing barriers to successful implementation of injury prevention and health promotion programs. Using this model to review the health promotion and injury prevention efforts implemented by the US military and those of partner nations helps to identify barriers to successful mitigation of their public health concerns (e.g., impaired mental health, obesity, musculoskeletal injury, poor sleep hygiene, suicide). The remainder of this chapter is dedicated to the application of the RE-AIM framework as an evaluation tool to review a variety of health promotion and injury prevention efforts in the military setting. We will identify individual and corporate barriers at the strategic, operational, and tactical levels and make recommendations regarding future program development and implementation that will improve observed outcomes .
R: Reach the Target Population
Reach is the first step in the RE-AIM model and is defined as an individual measure of participation [8]. Reach is the absolute number or percentage of target audience and representativeness of individuals who know about the initiative and are willing to participate in a given initiative [8]. On the surface, reach in a military setting appears easy as unit leaders can mandate that service members participate in approved, sanctioned programs. However, programs that are mandated often undermine adoption and long-term behavior change required for the program maintenance. For example, fitness programs are often mandated for active duty service members to help maintain readiness, including maintenance of physical performance requirements and height/weight standards. Despite years of program compliance, upon discharge from the military the average service member gains weight at a higher rate than active duty service members. Specifically, around the time of discharge from the military, men and women gain 12.6 or 13.9 lbs on average, respectively [10]. Higher rates of being physically inactive, smoking, alcohol consumption, and diabetes have also been reported after discharge from the military, when programs are no longer mandated [11]. Additionally, in the military setting, reach is often limited due to a diminished understanding of what programs and resources are available in the local environment. This is complicated by the high operational tempo, limited time due to competing demands, and a lack of leadership support for some of the programs. Reach in a military setting is also complicated by the fact that service members typically change duty locations every 3–4 years. Efforts to ensure similar resources are available across installations and can assist with maximizing awareness and ultimately the reach of an injury prevention program. With that in mind, the success of reaching the target population depends upon a greater understanding of the characteristics of the target population, specifically the psychosocial and medical history. For example, a history of previous musculoskeletal injury is one of the single most significant risk factors for subsequent injury, but this information is rarely relayed to unit commanders when service members change duty stations, which can limit the reach of injury prevention efforts.
Strategic-Level Barriers
A comprehensive injury prevention program that incorporates injury surveillance, injury prevention, early intervention, reintegration, and human performance optimization can help maximize reach through rapid identification and risk mitigation strategies. Recently the Army developed the Musculoskeletal Action Plan (MAP) [12]. The goal of the MAP was to provide a strategic framework to assess and address the impact of injuries on the military and to translate evidence-based interventions into standardized practices across military installations. By standardizing practices across Army Medicine, the MAP also helped to bring an Operating Company Model framework to the enterprise [13]. This framework establishes consistency across the organization, clarity in the standards and how the enterprise supports them, and a linkage between performance and outcomes/goals of the organization. A key aspect to standardizing practice across an organization such as the US military is a well-constructed communication strategy. The communication strategy should heighten awareness and provide guidance on how to access the resources to facilitate the reach of any injury prevention, performance optimization, or health promotion initiative.
Operational-Level Barriers
A program’s success at the organizational/operational level is dependent upon cooperation between the medical community and the unit leadership. The willingness of leaders at all levels to support efforts focused on improving medical readiness by investing time and resources is critical to decrease injuries and optimize performance. Organizational success requires a stepwise process be initiated. The first step is to implement a surveillance program that facilitates a thorough analysis of the extent of the problem while simultaneously identifying injury trends. Injury surveillance programs, in which results can be applied at the local level (i.e., military unit), are critical to gain the fidelity required for effective injury prevention programs. The second step is to identify gaps and perform a needs assessment of the entire population within the organization, paying particular attention to subgroups that are at the greatest risk. Units have a variety of assigned medical assets that can assist in this effort. In particular, the combat brigades have physical therapists who are taught how to implement surveillance techniques, develop injury prevention/human performance optimization programs as well as identify and treat musculoskeletal injuries. Although the brigade physical therapists can help lead an injury prevention effort, a well-designed program capitalizes on the knowledge, skills, and attributes of the entire medical team—to include the physicians, physician assistants, physical therapy technicians, medics, behavioral health providers, and nurses. With the support of the medical and unit leadership, this unique team of providers can maximize the time and minimize the external resources necessary to implement programs that will ultimately decrease injuries, optimize performance, and improve the overall medical readiness of the unit.
There are a variety of tools used for injury prediction with varying degrees of success [14–17]. Currently, the Army is conducting field research at the unit level to determine the most parsimonious set of tests to predict injury risk [18]. In addition to identifying individual risk factors for injury, a unit-facilitated injury prediction screening program can assist in providing information to mitigate injury risk at the organizational level. This can be powerful as it provides guidance to unit leaders in modifying and optimizing physical training programs by incorporating injury prevention exercises and techniques targeted at high-risk individuals and activities.
Once an injury occurs, early intervention is paramount in decreasing the number of lost duty days and long-term disability [5]. Thus, operational-level leadership needs to facilitate and encourage service members to seek care for an injury as targeted intervention and rehabilitation must reach the right injured population at the right time to have the desired outcome. Standardization at the operational level is a key to the success of these programs to help facilitate a quick return back to the unit.
Often, the injured service member cannot physically perform to the same level as the healthy population; if there is no program available that bridges the gap between the medical treatment facility treatment protocol and the return to normal unit activity, the service members risk reinjury [19, 20]. Thus, units should also develop programs that address the needs of this vulnerable population. Regardless of the program(s) chosen, it is clear that it must appeal across a broad spectrum using a variety of mediums in order to address the needs of the injured and non injured population.
Tactical-Level Barriers
The appropriateness of any program depends upon identifying the right individuals in the right environment at the right time and delivering that program in the right medium in order for it to achieve the desired outcomes. This is challenging, particularly since units tend to do organized physical training that may not incorporate ability groups. Furthermore, most units do not allow service members to do individual training programs during “unit” physical training hours. This challenge may be mitigated with establishing programs that assess the physical demands required to perform in a specific Military Occupational Specialty (MOS) and then designing a training regimen that meets those requirements. The Canadian military has piloted an online program which allows individual training of geographically separated individuals based on the physical demands of the MOS. By having a program that is both standardized, yet tailored to the individual’s needs, this program may ultimately improve the reach across multiple military settings (Active Duty, Reserve, and National Guard) and enhance injury prevention and human performance optimization efforts (www.DFit.ca).
Determining the appropriate reach is critical in establishing a program that meets the needs of the entire population served and, in particular, those with the greatest injury risk. Historically, the DoD designs programs for the masses, targeting the average healthy service member and often neglects programs that prevent injury or optimize performance. An integrated plan that addresses strategic, operational, and tactical barriers to reach can be utilized to optimize participation in injury prevention programs. A summary of potential barriers and solutions to enhance the reach of injury prevention and performance optimization is provided in Table 16.1.
Table 16.1
Potential barriers and solutions to enhance reach for the target population in military injury prevention programs [21]
Potential barrier | Potential solutions |
---|---|
Lack of knowledge of the program | An effective communication strategy that ensures appropriate dissemination of the information is required. Utilization of the operating company model across installations will help enhance reach by standardizing programs and availability at each installation |
Appropriate programming to meet the needs of the population | A comprehensive program includes implementing a surveillance program and utilizing a stratification system to properly identify groups who are (1) injured/profiled, (2) recovering from injury, (3) healthy. In all cases prevention of injury or reinjury is paramount |
Minimize time requirements | Incorporating programs during existing training will minimize additional time requirements. Injury prevention programs can be incorporated as part of unit physical training, squad leader training, and Sergeant’s Time Training to decrease the time burden and improve reach |
Deconflict schedule | Published program schedules that allow service members to utilize the appropriate venue depending on their needs: gym, pool, etc |
Support and knowledge of unit leadership | Develop support from unit leadership for the programs through professional development programs and informational handouts. Training material focused on leaders should clearly highlight the benefits to participation |
Recruitment and training of unit leadership | Identification of key unit leaders to facilitate the entire program from prevention to recovery to performance optimization while simultaneously incorporating prevention strategies to avoid injury or reinjury is essential to ultimately optimizing the reach of the program. Ensuring the key unit leaders are appropriately trained to implement the program successfully should enhance the ultimate reach of an ongoing and sustaining program |
Identifying the correct target audience | Development of a process to identify those at higher risk for injury is essential for determining the proper denominator for an injury prevention program. Injury prevention programs that target all individuals may have limited success due to recruitment of individuals already at low risk for injury and therefore limited engagement and utilization of the program |
E: Efficacy/Effectiveness
Effectiveness refers to the ability of the program to generate appropriate positive change in health and injury prevention, resulting in a positive impact on quality of life, performance, and military readiness . Abraham et al. [22] described the impact of a prevention program as a combination of the program’s reach and its effectiveness (I = R × E). Although evidence-based interventions that prevent injuries may have efficacy in a specific target population under controlled conditions, the effectiveness of delivering that program to a wider audience in real-world settings may not have the same results. While it is necessary for effective programs to have demonstrated efficacy, the program efficacy is not sufficient for programs to be effective in real-world settings. Specifically, effective injury prevention interventions should produce robust effects across multiple subpopulations and settings. Additionally, an effective program should have minimal to no adverse outcomes. Individuals developing injury prevention programs should account for the unanticipated negative effects that might be associated with labeling an individual at increased risk for injury and requiring additional or remedial training [23, 24].
Strategic-Level Barriers
One of the fundamental strategic imperatives is that evidence-based and effective programs are implemented for the target population [8]. Development of measures of performance (MOPs) and measures of effectiveness (MOEs) are essential tasks at the strategic level in optimizing program effectiveness. MOPs include measures of how the program was implemented and how the individual responded to the program. MOPs often help determine if the program resulted in changes in knowledge, attitudes, or beliefs. MOEs include outcome measures related to quality of life, performance, injury rates, disability, and military readiness .
Historically, most injury prevention programs in a military setting have focused on the training environment US Army Training and Doctrine Command (TRADOC) [25–27]. Although these training programs have demonstrated efficacy, the environment TRA-DOC is strictly controlled and the training regimens are often dictated. Therefore, when leaders apply lessons learned from injury prevention programs in the operational environment (Forces Command, FORSCOM), appropriate MOPs and MOEs are required to help ensure the program is effectively implemented in the new environment. Appropriately developed and implemented MOPs and MOEs allow for lessons learned to be captured to enhance long-term program effectiveness. Additionally, standardized MOPs and MOEs allow for comparative effectiveness of programs to be assessed across multiple environments. Finally, injury risk is multifactorial (environment, physiological, mental resilience, neuromuscular control, strength/endurance, stress, sleep, and nutrition) [28, 29]. Effective MOPs and MOEs would afford leaders at the strategic, operational, and tactical levels the ability to troubleshoot areas that need to be reinforced to maximize program effectiveness.
Operational-Level Barriers
At the operational level, leaders need evidence that the program is effective in order to implement and maintain the program over time. The leaders have to view the program as valuable and that implementation is worth the time and organizational investment. This is problematic as most injury prevention programs measure changes in the short term (6 months to 1 year) in a very specific and well-defined population [30–32]. These results may be less tangible when applied to a broader audience over longer periods of time [3]. Therefore, efficacious injury prevention programs ultimately need to demonstrate their effectiveness at the operational level with diverse populations under less controlled and more real-life settings.
Tactical-Level Barriers
Injury prevention and human performance optimization program success at the individual and tactical level has proven elusive. A potential barrier to both the reach and effectiveness of such programs is the health literacy of the broadly intended audience. Health literacy is the “capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” [33]. With respect to the RE-AIM model, health literacy pertains to reach both through the capacity to “obtain” health information and the ability to “process and understand” that directly affects efficacy and effectiveness of a program.
The 2003 National Assessment of Adult Literacy (NAAL) conducted by the US Department of Education identified health literacy issues across the full spectrum of otherwise literate Americans [34]. This direct assessment of 19,000 Americans’ ability to read, comprehend, and complete health-related literacy tasks reported that upwards of 36 % of those tested demonstrated basic or below basic health literacy. Effectively, those testing at these levels range between being nonliterate in English through the ability to read and understand “information in short, commonplace prose texts.” Stated another way, 36 % of those tested would be unable to “determine a healthy weight range for a person of a specified height, based on a graph that relates height and weight to body mass index (BMI)” [34]. Failure to operate at this level of health literacy in more than one third of the general audience is a significant challenge to reach by itself, but considering that there is a selection bias in those that volunteer to participate in research such as the NAAL, the results may underestimate the percentage of the general population with basic or below basic health literacy.
Due to the literacy and language skill requirements for entry into military service, the measured health literacy of military members is slightly higher than average, with 33 % operating at basic or below basic levels [34]. That being said, other subgroups of the military beneficiary population such as retirees over 65 years of age and military community members without any college or vocational education are more likely to have basic or below basic health literacy with 59 and 44 %, respectively. Further, those whose primary language was not English before attending school had an average health literacy score of below basic. These literacy challenges significantly affect the ability of health promotion, injury prevention, and performance optimization efforts to reach and achieve reported effectiveness levels.
Overcoming the barriers of health literacy in health promotion, injury prevention, and performance optimization programs in both military and community settings requires a multifactorial approach. Prose text should be written at the lowest possible reading level, available in a variety of languages, and be supported by simple imagery that effectively supports understanding of the text. PlainLanguage.gov is a clearing house for information organized to promote the development of government information that more effectively delivers the intended messages. They encourage clear and precise information written at a reading level appropriate for the audience that is delivered in short, active voice sentences and short paragraphs with descriptive headings (www.plainlanguage.gov/howto/guidelines/FederalPLGuidelines/FederalPLGuidelines.pdf).
Literacy challenges can also be mitigated through the delivery of materials through multimedia outlets that enhance simple prose with animation or video supplements. Components of the DoD are utilizing interactive web portals to deliver a variety of health promotion messages and supplementary materials (e.g., https://armyfit.army.mil and http://hprc-online.org). While appropriate for the typically technology savvy service member, this approach for an injury prevention program may fail to reach the elderly and those of lower socioeconomic status. These groups are typically of the lowest health status, and thereby, in greatest need of the information [34].
Although selection of evidence-based injury prevention programs is often the first step in implementation, it is not sufficient to ensure efficacy and effectiveness. Strategic leaders need to develop effective MOPs/MOEs to ensure proper implementation and lessons learned to allow for proper modifications and adaptation based on the different subpopulations and environments. Strategic and organizational leaders can utilize these MOPs/MOEs to validate the cost, time, and personnel required to maintain the program effectiveness over time (Table 16.2). Finally, at the tactical level, evidence-based programs need to address the health literacy of the target population to ensure efficacy and effectiveness of the program. An integrated plan that incorporates strategic, operational, and tactical barriers to implementation of effective programs can be utilized to optimize outcomes of injury prevention, health promotion, and performance optimization programs. A summary of potential barriers and solutions to enhance efficacy and effectiveness of injury prevention programs is provided in Table 16.2.
Potential barrier | Potential solutions |
---|---|
Knowledge, attitudes, and beliefs | Measures of performance (MOP) allow leaders to determine if the program is effectively changing knowledge, attitudes, and beliefs. These often change prior to behavior change and health outcomes |
Appropriately selected and measured health outcomes | Measures of effectiveness (MOE) allow leaders to determine if the program is having a positive or negative impact on health and readiness |
Sustainability | Lack of MOPs/MOEs may lead to an effective program being cancelled. Demonstrating prevention over time is a challenge. Appropriate MOPs/MOEs provide leaders with tangible measures of efficacy and effectiveness and should remain constant even when leaders change |
Different environments and subpopulations | Appropriate use of MOPs/MOEs allows standardized and evidence-based programs to be implemented in multiple environments with different subpopulations. Tracking lessons learned allows for programs to be adapted to the target population and setting |
Health literacy | Ensuring the program material targets, the appropriate health literacy level of the population will enhance program efficacy and effectiveness |
A: Adoption by Target Settings, Institution, and Staff
Adoption refers to the proportion of individuals or organizations that adopt the injury prevention program and the determination of associated barriers to adoption by nonparticipating individuals and organizations [7, 8]. To address low adoption rates, leaders developing injury prevention, health promotion, and performance optimization programs should consider many barriers that could negatively influence adoption of a new and innovative program. Injury prevention , health promotion, or performance optimization programs should be designed so they can be easily adopted across a variety of military settings (e.g., Active Duty, Reserve, and National Guard). To maximize adoption, a program should be adaptable to meet the specific needs of the target audience (special operations, combat units, combat support units, and combat service support units). Additionally, the program has to be adaptable in a variety of climates: hot, cold, humid as well as at higher altitudes. Can the program be adopted by high-risk populations in the typical constrained resource setting? Do the units have organic assets (e.g., medical staff, master fitness trainers, master resiliency trainers) to ensure the program is adopted properly? Is the program aligned with other programs so that it can be easily adapted and is synergistic with other demands and priorities? To maximize adoption, the program development team has to plan for the program’s costs and the level of resources and expertise required [3]. Padua et al. describe the following steps to help improve adoption of injury prevention programs: (1) establish support for the program and have key stakeholders identify barriers to implementation and strategies to overcome those barriers, (2) develop programs that apply the best available evidence that incorporates strategies to overcome the identified barriers, (3) ensure competency and self-efficacy of the trainers that will lead the program, (4) provide routine feedback and coaching to the trainers to ensure program fidelity, and (5) reduce feedback (both quantity and frequency) to the trainers based on their ability to effectively implement the program [35].
Strategic-Level Barriers
Ideally, leaders at the strategic level would develop and promote evidence-based injury prevention, health promotion, and performance optimization programs. As previously discussed, one of the historical problems associated with translating evidence-based injury prevention programs into practice is that research often focuses on program efficacy [3]. Efficacy studies tend to assess injury prevention programs in a singular setting to reduce variability. These studies typically utilize more resources (financial, personnel, and expertise) than will be available when the injury prevention program is implemented with a larger audience. Although it is important for initial studies to focus on internal validity to demonstrate the efficacy of the injury prevention program, they rarely address the needs of a broader audience which can limit adoption. Effectiveness studies that address how to implement the program in multiple settings and how it can be adapted to meet the needs of the different subpopulations are typically lacking [35].
One of the key elements of a program is to train strategic leaders to consider how to preserve the evidence-based elements of a program while also allowing the operational and tactical leaders the ability to adapt specific elements to maximize adoption for their environment and setting [3]. Therefore, a key planning factor that should be addressed by strategic leaders is to develop injury prevention, health promotion, and performance optimization programs that are both standardized and adaptable to meet the needs of the various organizations and the different risk levels of the target audience. For example, the Ranger Athlete Warrior (RAW) program was created to optimize human performance while minimizing injury risk [36]. The program had many standardized components that focused on the type of exercise (e.g., cardiovascular, strength, endurance, power, agility, balance, etc.) as well as proper dose (frequency, intensity). However, the program also provided flexibility in how it was executed at the tactical level by allowing the individual physical training leaders to select which exercises under the main categories would be performed tailored to the unit’s needs. To maximize adoption, strategic leaders should develop policy and doctrine that allows units to tailor the program based on the unit’s mission and needs while maintaining consistency in core features to ensure program effectiveness and adoption.
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